Painless limp as a presentation of pelvic eosinophilic granuloma in a child.

Painless limp in children continues to pose a diagnostic challenge. In the majority of the cases transient synovitis of the hip is the cause. However, bone tumours should be considered as a possibility and specifically looked for when a child continues to have ongoing symptoms. Failure to diagnose tumours at an early stage can lead to a poorer outcome. This case report describes a child with eosinophilic granuloma who presented with a progressive painless limp. It emphasises the need to look carefully at the pelvic bones when evaluating a hip radiograph.

Serology of abnormal fracture healing: the role of PIIINP, PICP, and BsALP.

OBJECTIVE: To determine whether poorly healing tibial shaft fractures exhibit a serological response of bone-specific alkaline phosphatase (BsALP), collagen I carboxy-terminal propeptide (PICP), collagen III amino-terminal propeptide (PIIINP), and collagen I carboxy-terminal telopeptide (ICTP) different from that of normally healing fractures. DESIGN: Prospective. PARTICIPANTS: Twenty consecutive patients with isolated tibial shaft fractures with or without fracture of the fibula. MAIN OUTCOME MEASUREMENTS: Assays of BsALP, PICP, PIIINP, and ICTP were performed with serum samples taken at standard intervals from twenty-four hours to twenty weeks after fracture. Fracture healing was assessed at five, ten, fourteen, and twenty weeks for clinical and radiological evidence of union. RESULTS: Seventeen fractures united within the twenty-week study period. The three fractures exhibiting delayed union demonstrated significantly lower PICP levels and marginally lower BsALP levels at twenty weeks. PIIINP levels were significantly higher in these three fractures at ten weeks. There was no difference in ICTP between the seventeen united and the three ununited fractures. CONCLUSIONS: This study identified three serological features of a poor healing response in tibial shaft fractures. First, matrix collagen I and III production in the first ten weeks of healing was adequate, with evidence of significantly increased production of type III collagen. Second, there was no serological evidence of a deficient osteoblast response, as indicated by normal levels of BsALP and PICP, during this early period. Third, evidence of a deficient osteoblast response appeared only at twenty weeks after injury.

Fibrous contracture of the elbow following cannulation of the antecubital fossa vein.

A case of flexion contracture of the elbow resulting from thrombophlebitis is described. Thrombophlebitis is a recognised complication following cannulation of the antecubital fossa vein. In severe cases a tender fibrous band is palpable. There are no previous reports of a contracture deformity occurring from such a fibrous band. This case therefore presents an unusual clinical manifestation of thrombophlebitis not previously described.

Serology of collagen types I and III in normal healing of tibial shaft fractures.

OBJECTIVES: To establish that serological indicators of synthesis of collagens I and III in humans with normally healing tibial shaft fractures will display a temporal pattern consistent with the sequence of expression of these collagens observed histologically in animal models of fracture healing. DESIGN: Prospective. SETTING: Four district general hospitals in the United Kingdom supported by an academic unit. PARTICIPANTS: Twenty consecutive patients with isolated tibial shaft fractures were studied. On clinical and radiological grounds, seventeen of the cases united within twenty weeks; these seventeen cases formed the material for this review. INTERVENTIONS: Nineteen patients were treated conservatively, and a functional brace was applied at five weeks. One patient treated with an external fixator had a functional brace applied at twelve weeks. MAIN OUTCOME MEASURES: Assays of collagen I carboxy-terminal propeptide (PICP), collagen III amino-terminal propeptide (PIIINP), and collagen I carboxy-terminal telopeptide (ICTP) were made in serum samples taken at standard intervals from twenty-four hours to twenty weeks after fracture. RESULTS: PICP showed a significant, transient early drop, whereas ICTP rose, indicating early breakdown with uncoupling of collagen I formation and degradation. PIIINP levels rose significantly from day eight to week five, in keeping with early expression of collagen III in experimental fracture callus. PICP levels showed a gradual rise, consistent with later expression of collagen I. CONCLUSIONS: The changes observed are in keeping with previous histological work on animal fracture models, suggesting that serological measures may reflect events occurring at the fracture site and thus offer a means for noninvasive and dynamic observation of collagen synthesis after fracture. Final proof that such measurements reflect bony healing per se, as opposed to events in other tissues, would require comparison with similar data from a soft tissue injury model.

Widening of the mediastinum following a sternal fracture.

Sternal fractures, once thought of as uncommon, occur with increasing frequency, parallelling the incidence of motor vehicle accidents. A fractured sternum can produce a widening of the mediastinum even in the absence of an aortic injury. The Advanced Trauma Life Support course teaches that a widening of the mediastinum after blunt chest injury is an indication for aortography. In this case report we recommend computerised axial tomography (CT) scan of the chest as the investigation of choice in the non-hypotensive patient who has sustained a fractured sternum after a blunt chest trauma, and who has widening of the mediastinum on the chest X-ray, with no other radiological features suggesting traumatic aortic rupture.

Traumatic radial head dislocation in children--a missed injury.

The purpose of this article is to remind accident and emergency doctors of an easily missed injury-isolated traumatic radial head dislocation in children. We present two such cases. This is a very uncommon injury and the diagnosis was overlooked in both cases. A high index of suspicion is necessary and careful examination of the radiographs is mandatory. The radiographic appearance of this injury is explained.

Acrylic bone-cement. Influence of mixer design and unmixed powder.

The effects of hand mixing with two different mechanical mixing systems (fixed versus rotating central axis) on unmixed powder content, macroporosity, density, and bending strength of acrylic bone-cement are compared. The effects of voids and unmixed powder on cement bending strength are also evaluated. In acrylic cement, both unmixed powder monomer and voids 1 mm and larger can be easily visualized and analyzed on radiographs of 3-mm-thick samples. Image analysis allowed demonstration of a significant increase in unmixed powder content (P < .0001), in cement prepared using a vacuum mixing system with a fixed central axis compared with both the rotating axis system and hand mixing. The rotating-axis system produced cement of higher density compared with hand mixing only (P = .004). There was a significant correlation between the number of voids measured per square centimeter and cement bending strength (P < .0001), as well as an independent and significant correlation between unmixed powder content and cement bending strength (P < .0001). Mechanical mixing using a fixed central axis produced significantly weaker cement compared with both hand mixing (P < .015) and the rotating-central-axis system (P < .0001). A 15% drop in strength between the two mechanical mixing systems was observed. It is therefore concluded that the use of different rotating systems in mechanical mixers can influence void and unmixed powder content and, consequently, the mechanical properties of acrylic cement, and that unmixed powder is an independent factor affecting the bending strength of the cement.

Endothelial stimulating angiogenic factor in early fracture healing.

The early vascular response is essential for the normal progress of fracture healing and fracture site blood flow has been shown to reach a peak in the first two weeks after injury. Angiogenesis is an important step in this response as new vessel formation is necessary to vascularize the fracture haematoma and the fracture gap. Changes in serum levels of a low molecular weight endothelial stimulating angiogenic factor (ESAF) have been previously reported in a group of four patients with tibial fractures. In this group, ESAF levels were measured on three occasions only and at different time intervals. We present a more detailed profile of serum ESAF level changes in the first 14 days after the fracture.

Transfusion needs in hip and knee arthroplasty.

A 12 months retrospective study of cross-match and transfusion practice in hip and knee arthroplasty in a general orthopaedic unit was carried out aiming to assess the transfusion needs for these procedures prior to enrolling future patients in a pre-donation program for autologous transfusion. The study revealed acceptable transfusion practice in the unit. For both procedures, over 75% of all transfusions were carried out in the peri-operative period. Eighty-nine percent of patients undergoing hip arthroplasty required transfusion with a maximum of three units, while a maximum of only two units were needed to meet the transfusion requirements of 86% of patients undergoing knee arthroplasty. In hip arthroplasty, the overall transfusion index (Ti), was 2.05, and this value did not vary significantly according to preoperative haemoglobin values. This was in contrast to knee arthroplasty, where the Ti was 2.9 in patients with preoperative haemoglobin value less than 11 g/dL compared to only 0.6 for haemoglobin value greater than 13 g/dL. In conclusion, in an autologous transfusion program, the availability of three units would satisfy the transfusion needs in 89% of hip arthroplasties, while the availability of two units would satisfy the needs in 86% of knee arthroplasties. Preoperative donation for knee arthroplasty with a haemoglobin level over 13 g/dL may prove wasteful as in our current practice, the transfusion index in this group of patients was only 0.6.

A new osteotome for performing chevron trochanteric osteotomy.

We report on the use of a new modified osteotome for performing chevron trochanteric osteotomy during hip arthroplasty. It is easy to use and the apex of the chevron is directed distally, thus producing a large segment of osteotomized trochanter, while avoiding the problems of fragmentation and splintering. At the end of the procedure, the trochanter is easily seated back within its concave bed, automatically achieving anatomical reduction and allowing easier fixation using the cruciate wiring technique. In a series of 77 primary hip arthroplasties, bony trochanteric union was achieved within 6 months in all patients.

The huckstep nail. Stable fixation of mechanically deficient femoral bone.

A Huckstep intramedullary nail was used to treat 23 fractures in which the femur was mechanically deficient due to pathologic fracture, nonunion, or complex fracture in osteoporotic bone. All nailings were performed by open surgery, and in some cases this was augmented by corticocancellous bone grafting. The Huckstep nail allows the use of multiple cross screws at 15-mm intervals, providing immediate and adequate stability with successful early postoperative weightbearing. The results at followup were good in functional and radiologic terms, with no cases of fixation failure or infection. The quality of instrumentation allowed the nail and screws to be inserted without difficulty; however, the straight profile of the nail may cause problems in the distal femur, as seen in 1 patient. The authors conclude that this device offers significant mechanical and practical advantages over most other forms of fixation, where early weightbearing is desired in the presence of deficient bone. It is not ideal for distal femoral fractures, particularly in the presence of excessive femoral bowing.

A cross-matching policy for fractures of the proximal third of the femur.

Cross-matching and transfusion policies for patients with a fracture of the proximal third of the femur are poorly formulated. A series of 90 patients who underwent operation for such fractures at a district general hospital were evaluated. Unnecessary cross-matching was most frequent in intracapsular fractures, and discrepancies in indications for postoperative transfusions were demonstrated. If postoperative transfusion is indicated for haemoglobin levels of less than 9 g/dl, we recommend routine preoperative cross-matching only for patients admitted with trochanteric fractures and haemoglobin levels between 10 and 12 g/dl. This practice is safe and is a potential area for savings in cost and resources.

The assessment of cutaneous blood flow with transoxode probe.

An experimental study on 12 healthy individuals was conducted over a period of six months, using the transoxode probe to assess cutaneous blood flow via measurements of transcutaneous oxygen tension (TcpO2) and relative heat power input (R.H.P.). The possible clinical use of the probe in peripheral vascular ischaemia was re-evaluated. The results were controlled with those of venous occlusion plethysmography, being a reliable means of assessing peripheral blood flow. The study revealed that changes in TcpO2 did not correlate significantly with alterations in skin perfusion mainly due to the lack of probe sensitivity. The clinical implications of such methods are discussed.